Owner's Manual: Not "Just" An Ankle Sprain

Preventing and recovering from ankle sprains includes being aware of their intricacies

Christie McMahon cringes when she hears runners dismiss an ankle twist as "merely" a sprain. That's because the 35-year-old marathoner and triathlete from Washington state believes that under appreciating the severity of a pair of sprains, years apart, set her up for a potentially career-ending injury.

The first sprain came when she was a high school middle-distance runner with a 2:20-ish PR in the 800. "I could feel something crunch," she says. But X-rays showed no break, so she went back to training. "If someone had done an MRI at that time, they might have said stop running to allow it to heal."

Fifteen years later, training for a marathon, she twisted it again. "It was fairly swollen, but I could still run," she says. "I was 6 miles into a 20-mile run. My brain said, 'Gotta do the 20.'"

She even ran the marathon. But last fall, after having three more marathons in the interim, the pain came back.

This time, she got the MRI and found she had torn a 5 x 9 millimeter hole in the cartilage between her tibia and her ankle. She had surgery, a procedure during which tiny holes were drilled into the bone in the hope of spurring the growth of new cartilage. It didn't work. This fall, she's scheduled for a second operation – a cartilage transplant that doctors predict will have a 60 percent likelihood of success. If that doesn't work, she's out of options: She won't even be able to jog.

Orthopedists divide ankle sprains into three categories. Grade I is a minor twist. Ligaments are stretched, but there are no major problems. Grade II is more severe, with increased tearing, while Grade III involves a major rupture that may need surgical repair.

Because severe ankle sprains can also involve minor fractures, doctors have developed a set of tests known as the Ottawa ankle rules. "Those are very good for initial screening for whether an X-ray is required," says Douglas Ivins, an assistant professor in the Department of Family Medicine at the University of Oklahoma, Tulsa.

Basically, you need an X-ray if you can't bear full weight on the affected leg, particularly if tenderness is located near certain bones. Hearing a pop or experiencing rapid swelling or discoloration are also major warning signs, Ivins says.

It's hard enough to get runners to take ankle sprains to a doctor. Getting them to take the rehabilitation seriously can be even more difficult.

But it's critically important. In 1993, M.L. Weinstein of Cherry Point Naval Hospital did an eye-opening study of Marines. Writing in the journal Military Medicine, Weinstein found that, even for Grade II sprains, failure to rehabilitate could delay return to full duty by several months.

Then, in 1999, Barbara Braun of HealthSystem Minnesota examined 467 ankle-sprain patients and found that the majority were still experiencing pain and weakness six to 18 months later. A quarter of them, she reported in Archives of Family Medicine, couldn't walk a mile without pain, and nearly 20 percent had re-sprained the ankle, often more than once.

"Ankle sprains," she wrote with typical scientific understatement, "may be more problematic than generally thought, or standard medical treatment may be inadequate."

Or, as McMahon discovered, "merely" and "ankle sprain" should not be uttered in the same breath. It's only our familiarity with this injury that causes us to dismiss it so lightly.

Fortunately, you can rehab most sprains, often quite quickly. Weinstein reported that he could get Marines back in training within two weeks. Better, from a runner's perspective, is that the rehab doesn't involve sitting around doing nothing. Sports medicine doctors recommend getting back to weight-bearing activity as soon as the ankle will tolerate it.

"What little epidemiological evidence there is suggests that the more quickly you begin rehabilitation, the more quickly you regain function," says Ivins, whose own article on ankles appeared in 2006, in American Family Physician.

Initially, of course, treatment is the classic "RICE" therapy: rest, ice, compression and elevation. An air cast or similar splint may also be helpful (and reassuring). Then you can proceed to cautious, non-weight-bearing exercises. The classics are drawing the alphabet in the air with your toes or working the ankle muscles gently with elastic therapy bands.

Don't forget to stretch the Achilles tendon, something that can be done sitting down, by running a towel beneath the ball of your foot and pulling gently toward your torso.

Next come simple weight-bearing exercises, like leaning against a wall, while squatting. "Then you progress to the point that you can walk and then run," says Ivins.

That's when most runners probably quit. And that is probably why some have recurrent trouble or continually weak ankles.

To protect your ankles from future damage, you need to do more than simply getting back into your running shoes. In a study in the British Journal of Sports Medicine, a team led by H. D. Hartsell of the University of Iowa found that weakness in ankle muscles is associated with chronic ankle instability. Of particular concern appear to be the peroneal muscles – the ones on the outside of the lower leg that might just help you recover if your foot starts to roll.

Even more important are proprioceptors: the nerves that provide the body's internal sense of position and balance. There are lots of balance drills, but the simplest is to stand on one foot, leg slightly bent. When you get good at that, change the bend of the knee. Then try it with your eyes closed. And be persistent. "Proprioception can take several months to come back," Ivins says.

Even if a sprain seems minor, pay attention if it doesn't recover on schedule (typically four to eight weeks) – especially if it's not your first. You might have a bone bruise or a stress fracture masquerading as a strain. Or ligaments might have been overstretched so many times they're having trouble recovering. Or the problem might signal transmitted stress from your foot, knee or hip.

"If you're having something where the pattern is getting worse, rather than better, that's something you need to have looked at," Ivins says.

McMahon agrees. "If I had only known how important the stability of the ankle is," she says. "An ankle sprain seems like such an insignificant injury in the grand scheme of things. I never thought it could be career-ending."

Strengthen Your Ankles

Do you roll your ankles a lot when you run, even on smooth pavement? To avoid ankle sprains or chronic injuries, strengthen the tendons and muscles in your ankles, feet and lower legs by doing the following exercises. Repeat each exercise three to six times several times each week.

Stretch your ankles regularly by rotating your foot several times in each direction. Also point your toes downward as far as possible for 10 seconds, followed by pointing your toes upward for 10 seconds.

Balance on one foot while standing on a thick pillow or couch cushion for 10 to 15 seconds at a time. Avoid looking at your feet or holding on to anything for support.

Sitting in a chair, keep the heel of one foot stationary and try to pick up a towel or T-shirt by scrunching up your toes.

Standing on one foot on the first step in a staircase or step stool, lower your free-hanging leg to the ground while maintaining control and balance with your stationary foot and slightly bent stationary leg.

Standing on both feet, raise your toes and midfoot off the ground and balance only on your heels for 10-15 seconds.

Standing on one foot, lift your heel off the ground and thrust upward so you're balancing (even if momentarily) on your forefoot.